Nailbed Injuries Treatment & Management
- Author: Darrell Sutijono, MD; Chief Editor: Trevor John Mills, MD, MPH more...
Emergency Department Care
Small (less than 25% of the nailbed) and painless subungual hematomas require no intervention, as the hematoma will eventually reabsorb. If the subungual hematoma covers more than 25% of the nailbed or is causing pain, the patient should be offered evacuation via trephination or nail removal (see Hand, Subungual Hematoma Drainage).
Historically, treatment of subungual hematomas covering 25-50% of the nailbed incluced removal of the nail and repair of any underlying lacerations. This practice came about because 50% of these hematomas had concurrent nailbed lacerations. The incidence of nailbed laceration increases to 94% when associated with a distal phalangeal fracture, regardless of the size of the hematoma.[4, 15, 16, 17, 18]
More recent studies have concluded that as long as the nail is still partially adherent to the nailbed or paronychia and is not displaced out of the nail fold, removal of the nail and repair of the nailbed does not improve outcomes versus simple trephination. Neither the size of the hematoma nor the presence of an associated fracture has been associated with adverse outcomes.[19, 13, 20] Trephination is contraindicated if a fracture requires surgical repair or if the germinal matrix is entrapped within the fracture, as delayed union or the formation of an intraosseous inclusion cyst may occur.
The advantages of simple trephination include less pain for the patient, shorter length of stay, and less costly intervention.
Evacuation of hematomas
Various methods of trephination exist (shown in the image below). The easiest and safest is to use an electric cautery, which melts a hole through the nail. Once the cautery encounters the underlying hematoma, the tip cools, preventing further injury to the nailbed. If the hole is of adequate size, blood will drain and relieve some pain and the pressure sensation for the patient.
A paper clip may also be used after it is heated until red hot.
An 18-gauge needle may be used by twirling the needle back and forth with slight downward pressure until dark blood return is noted. Use of an 18-gauge needle is less optimal because of the risk of injury to the nailbed once the nail has been penetrated. Alternatively, the needle may be directed at an oblique angle (45-60°) without applying pressure.
Another technique is use of a sterile 29-gauge extra-fine insulin syringe needle. Instead of penetrating the nail, the needle is inserted at the hyponychium parallel to the nail, aimed at the most distal portion of the hematoma. Care is taken to keep the needle closer to the nail versus the nail bed. Once the hematoma is penetrated, the needle may be withdrawn and light pressure placed on the nail will help with evacuation of the hematoma. This technique may obviate the need for digital block anesthesia, and also may be favorable in evacuating hematomas of the smaller toe nailbeds, where trephination is more difficult.
The use of a 2- or 3-mm biopsy punch has also been described.[23, 24] The biopsy punch is gently twirled back and forth with minimal pressure over the hematoma.
Principles of treatment include minimal debridement, preservation of as much tissue as possible, atraumatic wound care, and splinting with the nail or an alternative material. Nailbed repair is shown in the image below.
A digital block of 1% lidocaine hydrochloride without epinephrine provides anesthesia of sufficient duration for most repairs. Bupivacaine extends anesthesia time 4-8 hours for longer procedures.
Children may require procedural sedation and analgesia.
The hand should be prepared with povidone-iodine (Betadine) and covered with sterile drapes. The injured finger should be exsanguinated with a half-inch or 1-inch Penrose drain wrapped in a distal to proximal direction and placed around the base to serve as a tourniquet and provide a blood-free field.
The nail is elevated using the blades of either fine or curved iris scissors or small elevator scissors. Specific care is necessary to not injure the nailbed. A blunt dissecting technique should be used, and the scissors are placed gently underneath the nail until they reach the nail fold. Slowly open the scissors as it is removed. Care must again be taken to avoid further damage to the underlying nailbed or overlying nail fold. Once the nail is sufficiently separated from the nailbed, it is gently removed by applying firm and steady distal traction using a hemostat.
Lacerations to the nailbed should be repaired using 6-0 or smaller absorbable sutures. Minimal to no debridement should be performed because aggressive debridement may cause undue tension on the repair and results in scarring.
When repairing avulsed nails and nailbeds, if the nail is detached proximally, it must be removed to inspect for any damage to the nailbed. Careful inspection of the nail is important because often only a fragment of nailbed may be attached to the undersurface of the avulsed nail. Only outer and dorsal surfaces of the nail should be cleaned. Any large fragments of nailbed should be preserved for use as a free graft. Crushing injuries leave many small pieces of nailbed. If all fragments are not incorporated into the repair, they may grow independently and cause nail horns or spicules. If tissue is not available and the defect is small enough, the area will heal effectively by secondary intention.
Simple dorsal roof lacerations can often be repaired by accurately repairing the skin overlying the nail fold. However, if possible, suturing of the dorsal roof with a 7-0 chromic suture may provide more accurate repair. Associated paronychial injuries must be repaired and stented to prevent pterygium or adhesions, as it serves as a mold to coax nail to grow along a proper path. Distal phalangeal fracture reduction and healing is important to final nail formation. Poor reduction of the bone translates directly into irregularities of the nailbed.
The proximal nail should be reinserted into the nail fold. The replaced nail keeps the nail fold open for new nail growth and provides a protective cover for the nailbed and a precise template for new nail to follow as it regenerates. It also serves as a rigid splint for any underlying fractures and reduces postoperative discomfort and improves postoperative function. Some evidence suggests though that replacing the nail may be unnecessary and may delay wound healing and increase the risk of infection in children.
Before replacement, a small hole should be made in the nail, preferably so that it is not overlying the laceration. This is to allow drainage and thus prevent a growing hematoma to separate the nail from the nailbed.
The nail is then placed back in the nail fold as a stent and held in position by 5-0 or smaller nylon sutures placed by one of the techniques below:
Distally through the hyponychium and the nail
Through the nail and proximal to the nail fold 
Through a half-buried horizontal mattress suture placed down proximal to the nail fold into proximal nail then back out the nail fold
Through the paronychia and nail bilaterally
As a dorsal figure-of-eight suture  - A suture is placed transversely just distal to the hyponychium then placed proximal to the nail fold in the same direction and tied back to itself. If the nail slips laterally, 2 small vertical cuts may be made in the nail for the suture to catch upon.
In lieu of sutures, tissue adhesives such as Indermil ( n- butyl cyanoacrylate) or Dermabond (octyl-2-cyanoacrylate) may be applied along the perionychium after the nail is replaced.  Tissue adhesives are also a less invasive option for nailbed and nail repair.
- In one randomized controlled trial, nailbed laceration repair using Dermabond required less time with no difference in cosmetic or functional outcomes compared to suture repair. The adhesive should be allowed to dry prior to replacing the nail.
- Nail fragments may be repaired together first using adhesive, then secured into the nail fold by a thin layer placed under the nail, using gentle downward pressure while the adhesive dries.
- Alternatively, nail fragments may be pieced together on the nailbed, with a light coating of adhesive wiped or dripped between adjoining fragments and on skin adjacent to the perimeter of the nail. As the adhesive dries, use forceps to maintain external pressure.
- Chloramphenicol ointment may be used in a similar fashion for simple lacerations, with a small amount applied under the nail so that the ointment forms an adhesive layer as it is positioned into the nail fold.
Dress the injured finger with nonadherent gauze and 2-inch gauze roll then splint the finger.
A hand surgeon should be consulted for significantly avulsed nail matrix or for severe crush injuries.
Brown RE. Acute nail bed injuries. Hand Clin. 2002 Nov. 18(4):561-75. [Medline].
Inglefield CJ, D'Arcangelo M, Kolhe PS. Injuries to the nail bed in childhood. J Hand Surg [Br]. 1995 Apr. 20(2):258-61. [Medline].
de Alwis W. Fingertip Injuries. Emerg Med Australas. 2006 Jun. 18(3):229-37. [Medline].
Van Beek AL, Kassan MA, Adson MH, Dale V. Management of acute fingernail injuries. Hand Clin. 1990 Feb. 6(1):23-35; discussion 37-8. [Medline].
Loréa P. Primary care of nail traumas. Chir Main. 2013 Jun. 32 (3):129-35. [Medline].
Tully AS, Trayes KP, Studdiford JS. Evaluation of nail abnormalities. Am Fam Physician. 2012 Apr 15. 85 (8):779-87. [Medline].
Nanninga GL, de Leur K, van den Boom AL, de Vries MR, van Ginhoven TM. Case report of nail bed injury after blunt trauma; what lies beneath the nail?. Int J Surg Case Rep. 2015. 15:133-6. [Medline].
Chang J, Vernadakis AJ, McClellan WT. Fingertip injuries. Clin Occup Environ Med. 2006. 5 (2):413-22, ix. [Medline].
Zook EG. Anatomy and physiology of the perionychium. Hand Clin. 1990 Feb. 6(1):1-7. [Medline].
Zook EG. Understanding the perionychium. J Hand Ther. 2000 Oct-Dec. 13(4):269-75. [Medline].
Haneke E. Anatomy of the nail unit and the nail biopsy. Semin Cutan Med Surg. 2015 Jun. 34 (2):95-100. [Medline].
Guy RJ. The etiologies and mechanisms of nail bed injuries. Hand Clin. 1990 Feb. 6(1):9-19; discussion 21. [Medline].
Roser SE, Gellman H. Comparison of nail bed repair versus nail trephination for subungual hematomas in children. J Hand Surg [Am]. 1999 Nov. 24(6):1166-70. [Medline].
Gaston RG, Chadderdon C. Phalangeal fractures: displaced/nondisplaced. Hand Clin. Aug 2012. 28(3):395-401. [Medline].
Simon RR, Wolgin M. Subungual hematoma: association with occult laceration requiring repair. Am J Emerg Med. Jul 1987. 5(4):302-4. [Medline].
Mignemi ME, Unruh KP, Lee DH. Controversies in the treatment of nail bed injuries. J Hand Surg Am. 2013 Jul. 38 (7):1427-30. [Medline].
Garcia-Rodriguez JA. Draining a subungual hematoma: procedures and assessments video series. Can Fam Physician. 2013 Aug. 59 (8):853. [Medline].
Patel L. Management of simple nail bed lacerations and subungual hematomas in the emergency department. Pediatr Emerg Care. 2014 Oct. 30 (10):742-5; quiz 746-8. [Medline].
Meek S, White M. Subungual haematomas: is simple trephining enough?. J Accid Emerg Med. 1998 Jul. 15(4):269-71. [Medline].
Seaberg DC, Angelos WJ, Paris PM. Treatment of subungual hematomas with nail trephination: a prospective study. Am J Emerg Med. May 1991. 9(3):209-10. [Medline].
Tzeng YS. Use of an 18-gauge needle to evacuate subungual hematomas. J Emerg Med. Jan 2013. 44(1):196-7. [Medline].
Kaya TI, Tursen U, Baz K, Ikizoglu G. Extra-Fine Insulin Syringe Needle: An Excellent Instrument for the Evacuation of Subungual Hematoma. Dermatol Surg. 2003 Nov. 29(11):1141-3. [Medline].
Kain N, Koshy O. Evacuation of subungual haematomas using punch biopsy. J Plast Reconstr Aesthet Surg. Nov 2010. 63(11):1932-3. [Medline].
Khan MA, West E, Tyler M. Two millimetre biopsy punch: a painless and practical instrument for evacuation of subungual haematomas in adults and children. J Hand Surg Eur. Sep 2011. 36(7):615-7. [Medline].
O'Shaughnessy M, McCann J, O'Connor TP, Condon KC. Nail re-growth in fingertip injuries. Ir Med J. December 1990. 83:136-7. [Medline].
Miranda BH, Vokshi I, Milroy CJ. Pediatric nailbed repair study: nail replacement increases morbidity. Plast Reconstr Surg. April 2012. 129:1028. [Medline].
Harrison BP, Hilliard MW. Emergency department evaluation and treatment of hand injuries. Emerg Med Clin North Am. 1999 Nov. 17(4):793-822. [Medline].
Jeys LM, Khafagy R. A useful technique for securing nails: the figure-of-eight suture. Br J Plast Surg. 2001 Oct. 54(7):651. [Medline].
Hallock GG. Expanded applications for octyl-2-cyanoacrylate as a tissue adhesive. Ann Plast Surg. 2001 Feb. 46(2):185-9. [Medline].
Strauss EJ, Weil WM, Jordan C, Paksima N. A Prospective, Randomized Controlled Trial of 2-Octylcyanoacrylate Versus Suture Repair for Nail Bed Injuries. J Hand Surg [Am]. Feb 2008. 33(2):250-3. [Medline].
Richards AM, Crick A, Cole RP. A novel method of securing the nail following nail bed repair. Plast Reconstr Surg. 1999 Jun. 103(7):1983-5. [Medline].
Hallock GG, Lutz DA. Octyl-2-Cyanoacrylate adhesive for rapid nail plate restoration. J Hand Surg [Am]. 2000 Sep. 25(5):979-81. [Medline].
Pasapula C, Strick M. The use of chloramphenicol ointment as an adhesive for replacement of the nailplate after simple nail bed repairs. J Hand Surg [Br]. 2004 Dec. 29(6):634-5. [Medline].
Purcell EM, Hussain M, McCann J. Fashionable splint for nailbed lacerations: the acrylic nail. Plast Reconstr Surg. 2003 Jul. 112(1):337-8. [Medline].
Etoz A, Kahraman A, Ozgenel Y. Nail bed secured with a syringe splint. Plast Reconstr Surg. 2004 Nov. 114(6):1682-3. [Medline].
Bayraktar A, Ozcan M. A nasogastric catheter splint for a nailbed. Ann Plast Surg. 2006 Jul. 57(1):120. [Medline].